When they try to protect the few and harm the many ?

New measures of opioid utilization



The author is a PharmD, PGY-1 Pharmacy Practice Resident with the Veterans Affairs Connecticut Healthcare System 

Prescription drug overdoses have increased dramatically over the past two decades and are contributing to significant mortality and morbidity. The U.S. Department of Health and Human Services National Action Plan for Adverse Drug Event Prevention targets opioids as one of the three primary drug classes implicated in adverse drug events as they account for the greatest number of principally preventable harms.1 In 2013, over 50% of drug overdose deaths were the result of prescription medications.2 According to the National Vital Statistics System, the number of deaths per year attributed to prescription opioid medications reached 16,651 in 2010.2

Last year, the Pharmacy Quality Alliance (PQA) identified opioid abuse as a high priority area for measure development. PQA’s measures entitled “Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer” focus on opioid overutilization and target opioid overdose death prevention. Research has demonstrated that patients who take high dosages of opioid medications or obtain prescriptions from multiple providers may be at an increased risk of overdose. 3-6 The PQA opioid measures are intended for health plans to “examine the quality of use related to the dose of the medications over time, access to the medications, and the combination of both of these criteria.”7 The denominator for all three measures includes individuals with two or more prescription claims for opioids filled on at least two separate days in a twelve month period with a total equal to or greater than a fifteen day supply. The numerators of these measures correlate to inappropriate medication use, poor care-coordination, or doctor shopping.

According to the 2016 Centers for Medicare and Medicaid Services (CMS) Call Letter released in April, these PQA measures may be adopted as future display measures in the Medicare Star Rating System or used in the Overutilization Monitoring System (OMS).8


1. HHS. National Action Plan for Adverse Drug Event Prevention. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 2014. http://www.health.gov/hcq/ade.asp. Accessed April 30, 2015.

2. National Vital Statistics System. Multiple cause of death file. Atlanta: Centers for Disease Control and Prevention. 2012. http://www.cdc.gov/nchs/data/dvs/Record_Layout_2012.pdf. Accessed April 30, 2015.

3. CDC. Medicaid Patient Review and Restriction (PRR) Expert Panel Meeting. 2012. http://www.cdc.gov/drugoverdose/pdf/pdo_patient_review_meeting-a.pdf. Accessed April 30, 2015.

4. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose – A cohort study. Ann Intern Med. 2010; 152:85-92.

5. Paulozzi LJ, Kilbourne EM, Shah NG, et al. A history of being prescribed controlled substances and risk of drug overdose death. Pain Medicine. 2012 Jan;13(1):87-95.

6. Agency Medical Directors Group (AMDG). Interagency guideline on opioid dosing for chronic non-cancer pain: An educational aid to improve care and safety with opioid therapy. 2010 Update. www.cdc.gov/HomeandRecreationalSafety/Poisoning/brief.htm. Accessed April 30, 2015.

7. PQA performance measures. Pharmacy Quality Alliance website. http://pqaalliance.org/measures/default.asp. Updated April 2015. Accessed April 30, 2015.

8. CMS. Announcement of Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. 2015.

5 Responses

  1. On page 4 of the your 3rd source there: “While opioids have an important role in reducing
    pain among people with acute or chronic medical problems, the misuse and abuse of these drugs have increasingly become a serious public health and cost issue,8 especially among the Medicaid population. In Washington State, for example, the Medicaid population had a 5.7 times greater risk of dying from an opioid overdose than the non-Medicaid population. Despite being enrolled in the Washington PRR program (i.e., Medicaid patients with a troubling pattern of controlled substance use) PRR clients were at especially high
    risk of overdose; a staggering 1 in 170 died from an overdose of opioids each year.9
    Medicaid patients also have a higher rate of hospitalizations for poisoning by opioids and related narcotics than people who have other forms of insurance or even the uninsured.10 Similarly, the rate of emergency department visits for drug poisoning is much higher for Medicaid patients than for people in other payer groups.11
    Overall, people on Medicaid are prescribed opioid prescriptions at more than twice the rate as people with private insurance.12 Among Medicaid clients being treated for chronic pain, most of the prescriptions are consumed by the 10% of patients at the daily dosage of 100 morphine milligram equivalents or more, a level associated with greater risk of overdose.13” THIS IS BULLSHIT. There’s absolutely NO way that Medicaid beneficiaries are at more risk than others of overdose and I believe these numbers have been cooked! Literacy issues are the culprit with a great many overdoses, poisoning cases etc but this has been the case forever! The motivation for this concern is totally because of the also minuscule amounts of fraud and waste in federally funded programs. If they’d like to stop fraud and waste I suggest they start with Wall Street and Congress and not poor folks in pain of whom the vast majority wouldn’t want to run out of meds. I was prescribed Oxy for 6-7 years on Mefixaids dime and when the state and federal govt decided they could no longer afford to pay for brand name narcs for poor folks, that’s when they started scrutinizing our doctors and us, supposedly for our and the public good when it’s all $ motivated. This bullshit makes me livid as hell! If I can find a way, im going to sue the state and others for violating my health and disability rights all to save the taxpayers $ not because it’s medically sound for me or for public safety reasons. If violating my right to have my pain addressed, and exacerbating my pain and other health problems is medically sound, what were the expert pain management doctors who saw me for years and the Medicaid administrators who approved me annually for Oxy and Fentanyl etc doing for a those years? My problems are progressive and I have been told by some of the best PM docs in the Midwest that it is a permanent condition. Some days are better than most but if they would pay for the meds they once did ( or hey at least not blackball me with patient assistance, eh?) the last 4 years of my life wouldn’t have been spent primarily in my bed using my PC to distract me from my mismanaged pain which my current doc initially agreed wholeheartedly with me, that it was discrimination and that if you have private insurance or the ability to self-pay that you have no problem with ANY yet, strangely, every since I filed an appeal with Medicaid to try and get the right meds paid for and was denied, my doc has come under scrutiny and U.S. Trying to do a 180 degree tho I have no intention on letting them or any others forget what they say or the fact these meds were paid for by the state for many many years! Shameful despicable behaviors and BTW, who the hell are these handful of “experts” who are going to write our medical care instructions from behind the curtains??

    • I ask who they are cause I’d like to know exactly who to name in the federal lawsuit I plan to file! Ugh!

  2. The So called highratexof mortality is because people use pills to commit suicide and they are considering these as overdoses when they are meant by the person to die. it’s more propaganda from the failed war on drugs but people haven’t caught on yet. many many more people are helped to have a decent quality of life and remain functional because of opiates but they leave that out.

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